Credentialing Representative

Company: Highmark Health
Location: Oklahoma City
Posted on: August 5, 2022

Job Description:

**Company :**Highmark Wholecare**Job Description :**JOB SUMMARYThis job processes provider applications and re-applications including initial mailing, review, and loading. Maintains provider data base and communicates with providers by phone and mail regarding credentialing status and information. Performs credentialing, re-credentialing and related activities and coordinates credentialing verifications. Reviews and processes more complex additions, updates and deletions of provider information in the Dental Provider file database. Supports the implementation of new networks, systems, software, guidelines and other endeavors with a focus on group practices as opposed to individual providers. Depending on level, trains credentialing personnel in the use of various systems, software, databases and procedures. Participates in projects which streamline, automate or otherwise enhance credentialing functions.ESSENTIAL RESPONSIBILITIES:+ Credentials and re-credential providers.+ Contact providers or representatives by telephone or in writing to obtain additional information while processing their enrollment applications.+ Screen incoming applications and paperwork for completeness and accuracy and sends necessary paperwork to credentialing vendor.+ When necessary performs credentialing verifications and loads provider to appropriate networks and credentialing information to the provider database.+ Manage credentialing inventory, reports and projects to ensure all established time frames for completing work, reports and projects are met.+ Depending on level, train credentialing team in the use of various systems, software, databases, processes and procedures.+ Create anddistribute monthlyreports as assigned and handle complex and unusual or high-level credentialing issues.+ Support projects, audits, business partners, internal departments and external clients.+ Represent department as the Subject Matter expert.+ Pull and research necessary documentation for audits+ Support updates necessitated by our business partners, internal departments and external clients.+ Provide customer oversight for our customers who have unique requirements and timelines to ensure compliance.+ Depending on level, investigate interim license actions.+ Participate in projects which streamline, automate, or otherwise enhance credentialing functions.+ Other duties as assigned or requested.**QUALIFICATIONS****Minimum**+ High School Diploma or GED+ 3-5 years of related, progressive experience. Grandfathered experience requirements effective August 2016.+ Experience in Provider Data Management, Customer Services or Claims.+ Microsoft office experience (i.e. Word, Excel, PowerPoint, etc.)**Preferred**+ A familiarity with credentialing processes and the NCQA standards.+ Experience in the use of OnBase and Cactus systems.+ Experience with the Customer Service inquiry system or claims processing concepts.**Knowledge, Skills and Abilities**+ Good written and verbal communication+ Proficient use of Excel for spreadsheets, and WORD for mail merge letters.+ Proven diplomacy and a professional demeanor for effective communication with provider offices, internal personnel, vendors, accounts and committees.+ Strong written communication and presentation skills are essential.**SCOPE OF RESPONSIBILITY**Does this role supervise/manage other employees?No**WORK ENVIRONMENT**Is Travel Required?No**_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._**_Compliance Requirement:_** _This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies_Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.EEO is The LawEqual Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( _https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf_ )We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.orgCalifornia Consumer Privacy Act Employees, Contractors, and Applicants NoticeReq ID: J210398

Keywords: Highmark Health, Oklahoma City , Credentialing Representative, Other , Oklahoma City, Oklahoma